Provider Demographics
NPI:1669621983
Name:VITKOVIC, CORIE ANN (DMD)
Entity type:Individual
Prefix:DR
First Name:CORIE
Middle Name:ANN
Last Name:VITKOVIC
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 LAKESIDE CT
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-7354
Mailing Address - Country:US
Mailing Address - Phone:509-494-0121
Mailing Address - Fax:509-494-0171
Practice Address - Street 1:1417 LAKESIDE CT
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-7354
Practice Address - Country:US
Practice Address - Phone:509-494-0121
Practice Address - Fax:509-494-0171
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600352821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice